A cross-national survey of tube-feeding decisions in cognitively impaired older persons

Legal aspects of proxy practices in clinical psychiatry in India

Proxy procedures in psychiatry include proxy consultations, proxy prescriptions, covert and refill medications. Before Mental Healthcare Act (MHCA) 2017, there was minimal emphasis on the rights of individuals with Severe Mental Illness (SMI), leading family members to use proxy practices. With the new legislation, these practices have to be seen in a new light. Proxy consultations may be allowed for information, advice, etc. but not for giving medications or making a diagnosis. Proxy prescriptions can be given if the patient gives prior authorization or through nominated representative in advanced directive. Psychiatrists may consider covert medications if the patient lacks capacity, but not in emergencies. Medication refills can be given with physicians' recommendation for a specific duration.

Design Considerations for Embedded Pragmatic Clinical Trials of Advance Care Planning Interventions for Persons Living With Dementia

Advance care planning (ACP) is an important part of comprehensive care for persons living with dementia (PLWD). While many trials have established the efficacy of ACP in improving end-of-life communication and documentation of care preferences, there remains a gap in clinical usage. Embedded pragmatic clinical trials (ePCTs) may facilitate the uptake of evidence-based care into existing healthcare by deploying efficacious ACP interventions into real-world settings. However rigorous conduct of ePCTs of ACP for PLWD presents several unique methodological considerations. Here we describe a framework for the construction of these research studies, with a focus on distinguishing between the target of study: the PLWD, their care partners, or both. We outline specific considerations at each step of the research study process including 1) participant identification/eligibility, 2) participant recruitment/enrollment, 3) intervention implementation, and 4) outcome selection/ascertainment. These considerations are weighed in further detail by describing the approaches from three published trials. Specifically, we consider how potential challenges were overcome by tradeoffs in study design. Finally, we offer directions for future growth to advance ePCTs for ACP among PLWD and catalyze future research.

Clinician's attitude to enteral nutrition with percutaneous endoscopic gastrostomy: a survey in China

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG) is recommended for long-term enteral nutrition. However, long-term nasogastric (NGT) feeding is still commonplace in China. We surveyed Chinese clinicians' opinions toward PEG feeding in order to identify the potential barriers to acceptancy of PEG feeding.

METHODS

A self-reported questionnaire was developed and distributed to 600 doctors. Five-point Likert scales were used for most responses.

RESULTS

Of 525 respondents, the mainly nutritional support method was NGT while PEG was less used. Doctors working in the tertiary class A hospitals and radiotherapy department were more likely to choose PEG feeding (p = 0.000). Overall, 241 (46%) participants did not know PEG and 284 (54%) have different understanding degree of PEG. Age (p = 0.002), working life (p = 0.044) and professionalism (p = 0.005) were significantly related to the understanding of PEG. Levels of agreement was high (score of 3.47) for using PEG in patients with prolonged stroke-associated dysphagia. There was high agreement level in the statement that PEG was unnecessary when NGT could sustain the basic needs of patients, though better outcome can be predicted with PEG feeding. The highest scoring factor (score of 3.91) that influenced clinicians' choice of PEG was resistance from patients and families and the second one was the poor cooperation among departments (score of 3.80).

CONCLUSIONS

Doctors' insufficient knowledge of PEG feeding, resistance from patients and families, poor cooperation among departments, all these factors leading physicians to prefer more conservative treatment to avoid disputes rather than better ones.

Tube Feeding Patients With Dementia

As the population ages, the incidence of dementia increases. All types of dementia, whether they are reversible or irreversible, lead to loss of intellectual function and judgment, memory impairment, and personality changes. The skills to feed oneself, use eating utensils, and consume items recognized as food, thereby maintaining nutrition status, may be lost as dementia progresses. Reports indicate that nutrition status may be maintained when patients are hand fed, but this is labor intensive and therefore expensive. Feeding via a percutaneous endoscopic gastrostomy tube is often chosen as an acceptable alternative. Research indicates that there is little benefit in this population when aggressive nutrition support is instituted. Providing tube feeding to patients with dementia does not necessarily extend life, increase weight, or reduce the incidence of pressure ulcers or aspiration. There are many legal and ethical issues involved in the decision to place a feeding tube in demented patients. The primary issue in patients with dementia may be autonomy and the right of an individual to decide whether or not a tube should be placed at all. Legally, there is clear precedent that the courts see the insertion of a feeding tube as extraordinary care that the patient has the right to refuse. However, much of case law is derived from cases of patients who were in a persistent vegetative state. Advance directives help to determine what the patient would want for himself. Considering all the options before the patient can no longer make decisions is the most desirable course.

Perceptions of Healthcare Professionals on the Usage of Percutaneous Endoscopic Gastrostomy in a Teaching Hospital from a Middle-Income South East Asian Country

OBJECTIVE

To explore the perceptions of healthcare professionals' (HCPs) in a South East Asian nation towards percutaneous endoscopic gastrostomy (PEG) feeding.

DESIGN

Semi-structured, qualitative interviews.

SETTINGS

A teaching hospital in Kuala Lumpur, Malaysia.

PARTICIPANTS

A total of 17 healthcare professionals aged 23-43 years, 82% women.

RESULTS

Thematic analysis revealed five themes that represent HCPs' perceptions in relation to the usage of PEG feeding: 1) knowledge of HCPs, 2) communication, 3) understanding among patients, and 4) financial and affordability.

CONCLUSION

The rationale for reluctance towards PEG feeding observed in this regions was explained by lack of education, knowledge, communication, team work, and financial support. Future studies should assess the effects of educational programmes among HCPs and changes in policies to promote affordability on the utilization of PEG feeding in this region.

Cognitive Citizenship: Access to Hip Surgery for People with Dementia

Dementia and chronic hip disease are both more prevalent with advancing age. Given this, the number of people with both dementia and hip disease is likely to increase in an ageing population such as the UK. This article raises questions about how people with dementia and chronic hip disease are conceptualized in the context of evidence-based medicine, and whether this conceptualization may limit unfairly their access to surgical services. The published clinical research discourse at the interface of hip disease and dementia is taken as an ‘evidence-base’, and is evaluated in terms of its suitability for informing professional decisions about viability for surgery. The analysis suggests that the outcomes criteria used to determine patient viability serve to discriminate unfairly against people with dementia. If such discrimination exists, it necessarily militates against the promotion of health-related citizenship rights of the cognitively impaired, creating an evidence-based culture that encourages a problematic model of cognitive citizenship.

Trends regarding percutaneous endoscopic gastrostomy: A nationwide population-based study from 1997 to 2010

Percutaneous endoscopic gastrostomy (PEG) is widely used in patients requiring long-term tube feeding. Traditional PEG studies usually focused on practical, technical, and ethical issues. There have been little epidemiological studies on PEG utilization and services in Asia. We evaluated the changes in PEG utilization, patient selection, patient characteristics, and medical service in Taiwan from 1997 to 2010.This retrospective study analyzed the data of patients admitted for PEG tube placement according to the International Classification of Diseases, Ninth Revision (procedure code 43.11) extracted from the National Health Insurance database between 1997 and 2010.From 1997 to 2010, the incidence of PEG increased from 0.1 to 3.8/10 population and incidence of PEG among aged patients increased from 0.9 to 19.0/10 population. Compared 1997-2004 to 2005-2010 periods, the percentage of cerebrovascular diseases decreased and esophageal cancer increased in the later period. PEG was mainly performed in male patients and at medical centers. Medical costs, Charlson Comorbidity Index (CCI) scores, and post-PEG mortality rates were higher in the 2005-2010 period than in the 1997-2004 period.PEG procedures are being increasingly performed in Taiwan, and changes in patient selection were noted. The seriousness of accompanying diseases, medical costs, and post-PEG mortality rates in patients undergoing PEG has increased. The present findings may help in the implementation of PEG, relocation of medical resources, and improvement of PEG-related care.

Development and psychometric properties of the family distress in advanced dementia scale

OBJECTIVE

The majority of scales to measure family member distress in dementia are designed for community settings and do not capture the unique burdens of the nursing home (NH) environment. We report the psychometric properties of a new Family Distress in Advanced Dementia Scale for use in the NH setting.

DESIGN, SETTING, PARTICIPANTS

Cross-sectional questionnaire of 130 family member health care proxies of NH residents with advanced dementia in 31 Boston-area NHs.

METHODS

Thirty-one initial items were evaluated, measuring the frequency over the past 3 months of sources of distress. Exploratory factor analysis identified domains of distress; Cronbach's alpha was computed for each domain. Associations between the domains and other measures were evaluated using Pearson correlation coefficients, including measures of depression (PHQ-9), satisfaction with care (Satisfaction with Care at the End-of-Life in Dementia [SWC-EOLD]), and caregiver burden (Zarit Burden Interview short version).

RESULTS

Factor analysis suggested 3 domains: emotional distress (9 items), dementia preparedness (5 items), and NH relations (7 items). Cronbach's alpha coefficients were 0.82, 0.75, and 0.83 respectively. The PHQ-9 correlated most strongly with the emotional distress factor (r = 0.34), the SWC-EOWD correlated most strongly with the NH relations factor (r = 0.35), as did the Zarit Burden Scale (r = 0.50).

CONCLUSIONS

The Family Distress in Advanced Dementia Scale encompasses 3 domains of distress. This scale represents a much needed tool to assess distress among family members of NH residents with advanced dementia and provides a metric to evaluate interventions in the population.

Healthcare Proxy Awareness of Suspected Infections in Nursing Home Residents with Advanced Dementia

OBJECTIVES

To determine healthcare proxy involvement in decision-making regarding infections in individuals with advanced dementia.

DESIGN

Prospective cohort study.

SETTING

Thirty-five Boston-area nursing homes (NHs).

PARTICIPANTS

NH residents with advanced dementia and their proxies (N = 362).

MEASUREMENTS

Charts were abstracted monthly (up to 12 months) for documentation of suspected infections and provider-proxy discussions for each episode. Proxies were interviewed within 8 weeks of the infection to determine their awareness and decision-making involvement. Factors associated with proxy awareness and discussion documentation were identified.

RESULTS

There were 496 suspected infections; proxies were reached for interview for 395 (80%). Proxy-provider discussions were documented for 207 (52%) episodes, yet proxies were aware of only 156 (39%). Proxies participated in decision-making for 89 (57%) episodes of which they were aware. Proxy awareness was associated with antimicrobial use (adjusted odds ratio (AOR) = 3.43, 95% confidence interval (CI) = 1.94-6.05), hospital transfer (AOR = 3.00, 95% CI = 1.19-7.53), infection within 30 days of death (AOR = 3.32, 95% CI = 1.54-7.18), and fewer days between infection and study interview (AOR = 2.71, 95% CI = 1.63-4.51). Discussion documentation was associated with the resident residing in a dementia special care unit (AOR = 1.71, 95% CI = 1.04-2.80), the resident not on hospice (AOR = 3.25, 95% CI = 1.31-8.02), more provider visits (AOR = 1.71, 95% CI = 1.07-2.75), proxy visits of more than 7 h/wk (AOR = 1.93, 95% CI = 1.02-3.67), and episode within 30 days of death (AOR = 3.99, 95% CI = 1.98-8.02).

CONCLUSION

Proxies are unaware of and do not participate in decision-making for most suspected infections that NH residents with advanced dementia experience. Proxy awareness of episodes and documentation of provider-proxy discussions are not congruent.

Feeding tubes for older people with advanced dementia living in the community in Israel

BACKGROUND

Feeding tubes to address eating problems of older people with advanced dementia (OPAD) has been studied primarily in nursing homes.

OBJECTIVES

To examine the prevalence of feeding tube use among OPAD living in the community; to evaluate the characteristics, quality of care, and the burden on caregivers.

METHODS

A cross-sectional survey of 117 caregivers of OPAD living in the community.

RESULTS

Of 117 patients, 26% had feeding tubes. Compared to nonusers, feeding tube users had more use of restraints, greater problems with swallowing, more emergency room visits, and were more likely to have a legal guardian. In addition, caregivers of feeding tube users were older and reported very heavy burden of care. Half of the caregivers reported that the medical team consulted them before insertion of the feeding tube.

CONCLUSION

Feeding tube use in OPAD in the community is associated with negative outcomes and increased caregiver burden.

Prospective evaluation of peristomal cutaneous changes among patients with long-term percutaneous endoscopic gastrostomy

OBJECTIVE

Percutaneous endoscopic gastrostomy (PEG) is the most commonly used procedure in patients requiring long-term tube feeding. Lack of universal terminology and variations in the description of long-term PEG cutaneous lesions make it difficult for clinicians to interpret, communicate, and formulate a plan of treatment. The authors designed a prospective study to assess the long-term PEG cutaneous lesions and the healthcare utilization.

PATIENTS AND METHODS

After the PEG procedure, patients followed up for more than 12 months were included. Results of physical examination of the PEG cutaneous lesions were recorded. Laboratory tests, including the standard urine strip test, which detected the presence of bilirubin, microbiologic culture, as well as computed tomography, were applied in patients with PEG long-term cutaneous complications. Unscheduled hospital visits also were recorded.

RESULTS

The mean follow-up duration after PEG was 28 ± 15 months. Among patients with long-term PEG, 33.6% of the patients had normal skin, 31.0% had skin erythema, 21.2% had wound discharge, 24.8% had granulation tissue, 15.0% had postinflammatory hyperpigmentation, 15.9% had scarring, 5.3% had side torsion, 29.2% had stoma retraction, and 5.3% had bulging lesions. Urine strip test can differentiate gastric content leakage from purulent exudate/serous fluid. All patients with bulging lesions required hospitalization.

CONCLUSION

Long-term PEG cutaneous problems are common. Appropriate physical examinations and laboratory tests can provide evidence to identify the causes, treat the patients with the PEG cutaneous problems, and decrease the risk for potential unscheduled hospital visits.

Emergency department visits and hospitalizations by tube-fed nursing home residents with varying degrees of cognitive impairment: a national study

Background

Numerous studies indicate that the use of feeding tubes (FT) in persons with advanced cognitive impairment (CI) does not improve clinical outcomes or survival, and results in higher rates of hospitalization and emergency department (ED) visits. It is not clear, however, whether such risk varies by resident level of CI and whether these ED visits and hospitalizations are potentially preventable. The objective of this study was to determine the rates of ED visits, hospitalizations and potentially preventable ambulatory care sensitive (ACS) ED visits and ACS hospitalizations for long-stay NH residents with FTs at differing levels of CI.

Methods

We linked Centers for Medicare and Medicaid Services inpatient & outpatient administrative claims and beneficiary eligibility data with Minimum Data Set (MDS) resident assessment data for nursing home residents with feeding tubes in a 5% random sample of Medicare beneficiaries residing in US nursing facilities in 2006 (n = 3479). Severity of CI was measured using the Cognitive Performance Scale (CPS) and categorized into 4 groups: None/Mild (CPS = 0-1, MMSE = 22-25), Moderate (CPS = 2-3, MMSE = 15-19), Severe (CPS = 4-5, MMSE = 5-7) and Very Severe (CPS = 6, MMSE = 0-4). ED visits, hospitalizations, ACS ED visits and ACS hospitalizations were ascertained from inpatient and outpatient administrative claims. We estimated the risk ratio of each outcome by CI level using over-dispersed Poisson models accounting for potential confounding factors.

Results

Twenty-nine percent of our cohort was considered “comatose” and “without any discernible consciousness”, suggesting that over 20,000 NH residents in the US with feeding tubes are non-interactive. Approximately 25% of NH residents with FTs required an ED visit or hospitalization, with 44% of hospitalizations and 24% of ED visits being potentially preventable or for an ACS condition. Severity of CI had a significant effect on rates of ACS ED visits, but little effect on ACS hospitalizations.

Conclusions

ED visits and hospitalizations are common in cognitively impaired tube-fed nursing home residents and a substantial proportion of ED visits and hospitalizations are potentially preventable due to ACS conditions.

A decision aid regarding long-term tube feeding targeting substitute decision makers for cognitively impaired older persons in Japan: a small-scale before-and-after study

BACKGROUND

In Japan, there is no decision-making guide regarding long-term tube feeding that specifically targets individuals making decisions on behalf of cognitively impaired older persons (substitute decision makers). The objective of this study was to describe the development and evaluation of such a decision aid.

METHODS

In this before-and-after study, participants comprised substitute decision makers for 13 cognitively impaired inpatients aged 65 years and older who were being considered for placement of a percutaneous endoscopic gastrostomy tube in acute care hospitals and mixed-care hospitals in Japan. Questionnaires were used to compare substitute decision makers' knowledge, decisional conflict, and predisposition regarding feeding tube placement before and after exposure to a decision aid. The acceptability of the decision aid was also assessed. Paired t-tests were used to compare participants' knowledge and decisional conflict scores before and after using the decision aid.

RESULTS

Substitute decision makers showed significantly increased knowledge (P < .001) and decreased decisional conflict (P < .01) regarding long-term tube feeding after using the decision aid. All substitute decision makers found the decision aid helpful and acceptable.

CONCLUSIONS

The decision aid facilitated the decision-making process of substitute decision makers by decreasing decisional conflict and increasing knowledge.

What is family-centered care for nursing home residents with advanced dementia?

To understand family members' perspectives on person- and family-centered end-of-life care provided to nursing home (NH) residents with advanced dementia, we conducted a qualitative follow-up interview with 16 respondents who had participated in an earlier prospective study, Choices, Attitudes, and Strategies for Care of Advance Dementia at End of Life (CASCADE). Family members of NH residents (N = 16) with advanced dementia participated in semistructured qualitative interviews that inquired about overall NH experience, communication, surrogate decision making, emotional reaction, and recommendations for improvement. Analysis identified 5 areas considered important by family members: (1) providing basic care; (2) ensuring safety and security; (3) creating a sense of belonging and attachment; (4) fostering self-esteem and self-efficacy; and (5) coming to terms with the experience. These themes can provide a framework for creating and testing strategies to meet the goal of person- and family-centered care.

Nutrition, older people and the end of life

Older patients are at increased risk of malnutrition, resulting in higher mortality and morbidity. It is important to address nutritional need early in order to prevent or mitigate these adverse outcomes. Decisions about nutrition and hydration for older people presenting with acute illness or evolving multiple long-term conditions present great difficulty to all involved. Clinicians are more likely to encounter such situations as the population of older people with frailty syndromes expands. The clinical evidence base to guide such decisions is sparse and largely unhelpful. Clinicians must recognise their role in these difficult decisions. In addition to familiarity with the clinical evidence base, they must be fully informed of the legal, professional and moral context of the decisions with which they are faced. Responsible clinicians have a professional duty to elicit, understand and weigh the views of their patient, and where necessary their representatives. This can only be undertaken through a process of facilitated patient choice utilising the available legal and professional decision-making frameworks. Any decision relating to clinically assisted nutrition and/or hydration in a frail older person who is considered to be nearing the end of their life must also include explicit consideration of the needs of that individual for formalised palliative care.

Evaluation of an intra-institutional diabetes disease management program for the glycemic control of elderly long-term care diabetic patients

AIM

Increasing numbers of nursing home elderly patients suffer from diabetes requiring individually optimized glycemic control. This is a complicated challenge because of their high comorbidity level, and heterogeneous and changing eating status varying from independent to dysphagia and enteral feeding. In order to cope with these complex needs, we developed and implemented a diabetes disease management program. The purpose of the present study was to evaluate this program.

METHODS

We used the point prevalence approach by checking for fasting blood glucose, glycated hemoglobin and other routine biochemical tests. Eating status was evaluated by the Functional Outcome Swallowing Scale. Details about the diabetes disease management program are given in the text.

RESULTS

A total of 86 (36%) of the 234 patients on the study day were diabetics. Of these, 80 were eligible for the study. Their mean fasting blood glucose was 143.1 ± 60.6 mg/dL. The mean glycated hemoglobin level was 7.23 ± 1.39%.

CONCLUSION

No case of hypoglycemia was detected on the examination day, or during the preceding 3 weeks. No significant difference was found among the different Functional Outcome Swallowing Scale categories. These results are within satisfactory range for this category of patients suggesting that our diabetes disease management program contributes to a better glycemic control.

How are treatment decisions made about artificial nutrition for individuals at risk of lacking capacity? A systematic literature review

BACKGROUND

Worldwide, the number of individuals lacking the mental capacity to participate in decisions about their own healthcare is increasing. Due to the ageing global population and advancing medical treatments, there are now many more people living longer with neurological disorders, such as dementia, acquired brain injuries, and intellectual disabilities. Many of these individuals have feeding difficulties and may require artificial nutrition. However, little is known about the decision-making process; the evidence base is uncertain and often ethically complex. Using the exemplar of artificial nutrition, the objective of this review is to examine how treatment decisions are made when patients are at risk of lacking capacity.

METHODS AND FINDINGS

We undertook a systematic review according to PRISMA guidelines to determine who was involved in decisions, and what factors were considered. We searched PubMed, AMED, CINAHL, EMBASE, PsychINFO, and OpenSigle for quantitative and qualitative studies (1990-2011). Citation, reference, hand searches and expert consultation were also undertaken. Data extraction and quality assessment were undertaken independently and in duplicate. We utilised Thomas and Harden's 'Thematic Synthesis' for analysis. Sixty-six studies met inclusion criteria, comprising data from 40 countries and 34,649 patients, carers and clinicians. Six themes emerged: clinical indications were similar across countries but were insufficient alone for determining outcomes; quality of life was the main decision-making factor but its meaning varied; prolonging life was the second most cited factor; patient's wishes were influential but not determinative; families had some influence but were infrequently involved in final recommendations; clinicians often felt conflicted about their roles.

CONCLUSIONS

When individuals lack mental capacity, decisions must be made on their behalf. Dynamic interactive factors, such as protecting right to life, not unnecessarily prolonging suffering, and individual preferences, need to be addressed and balanced. These findings provide an outline to aid clinical practice and develop decision-making guidelines.

Diagnosis and management of Alzheimer's disease: past, present and future ethical issues

There is great interest in the ethical issues associated with Alzheimer's disease (AD) and related dementias given the prevalence of AD and the evolving neuroscience landscape in matters of diagnoses and therapeutics. Much of the ethics discussion arises in the tension between the principle of not doing harm (principle of non-maleficence) in this vulnerable population and the development of effective treatments (principle of beneficence). Autonomy and capacity issues are also numerous, wide-ranging, and concern (1) day to day affairs such as driving safely and spending money wisely, (2) life-time events such as designating a legal representative in case of incapacity, making a will, (3) consenting to treatment and diagnostic procedures, (4) participating in research. The latter issue is particularly thorny and illustrates well the complexity of tackling concerns related to capacity. The impetus to protect AD patients has partly led to ethics regulation and policies making research on inapt patients more difficult because of stringent requirements for signed informed consent or for showing the value of the research to this specific patient population. New issues are arising that relate to earlier diagnosis using biomarkers and (possibly soon) the use of drugs that modify disease progression. We here summarize and discuss the different ethical issues associated with AD from a historical perspective, with emphasis on diagnostic and treatments issues.

Difficulties with percutaneous endoscopic gastrostomy (PEG): a practical guide for the endoscopist

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG) is a widely used and effective means of providing long-term nutrition in patients with inadequate oral intake. The demand for this intervention has risen steadily since the early 1990s. Endoscopists who perform PEG insertion have become increasingly concerned about inappropriate use of this intervention.

AIMS

This review addresses the particular areas of difficulty, namely, dementia, stroke, aspiration pneumonia and use of PEG to facilitate discharge from hospital.

METHODS

A Pubmed literature search and the author's personal experience.

CONCLUSIONS

Strategies for improving patient selection and a practical approach to difficult decisions are described.

Decision-making and outcomes of feeding tube insertion: a five-state study

OBJECTIVES

To examine family member's perceptions of decision-making and outcomes of feeding tubes.

DESIGN

Mortality follow-back survey. Sample weights were used to account for oversampling and survey design. A multivariate model examined the association between feeding tube use and overall quality of care rating regarding the last week of life.

SETTING

Nursing homes, hospitals, and assisted living facilities.

PARTICIPANTS

Respondents whose relative had died from dementia in five states with varying feeding tube use.

MEASUREMENTS

Respondents were asked about discussions, decision-making, and outcomes related to their loved ones' feeding problems.

RESULTS

Of 486 family members surveyed, representing 9,652 relatives dying from dementia, 10.8% reported that the decedent had a feeding tube, 17.6% made a decision not to use a feeding tube, and 71.6% reported that there was no decision about feeding tubes. Of respondents for decedents with a feeding tube, 13.7% stated that there was no discussion about feeding tube insertion, and 41.6% reported a discussion that was shorter than 15 minutes. The risks associated with feeding tube insertion were not discussed in one-third of the cases, 51.8% felt that the healthcare provider was strongly in favor of feeding tube insertion, and 12.6% felt pressured by the physician to insert a feeding tube. The decedent was often physically (25.9%) or pharmacologically restrained (29.2%). Respondents whose loved ones died with a feeding tube were less likely to report excellent end-of-life care (adjusted odds ratio=0.42, 95% confidence interval=0.18-0.97) than those who were not.

CONCLUSION

Based on the perceptions of bereaved family members, important opportunities exist to improve decision-making in feeding tube insertion.

Chinese familial tradition and Western influence: a case study in Singapore on decision making at the end of life

Decision making for an incompetent patient at the end of life is difficult for both family members and physicians alike. Often, palliative care teams are tasked with weaving through opinions, emotions, and goals in search for an amenable solution. Occasionally, these situations get challenging. We present the case of an elderly Chinese Singaporean with metastatic cancer, whose family and physicians had conflicting goals of care. The former was adamant on treating the patient's disease with an untested drug, whereas the latter aimed to treat his symptoms with more conventional medication. Drug-drug interactions prevented treatment with both. Beginning with a discussion of the patient's best interest, we delve into the Singaporean context to show how culture affects medical decision making. Confucianism and filial piety are the values on which this family's workings were based. In an analysis of what this entails, we attempt to explain the significant and assertive family involvement in the decision-making process and their insistence on using novel medications, having exhausted conventional interventions. Within this mix were Western influences, too. Through the Internet, family members have become more informed and empowered in decision making, wresting the traditional paternalistic role of physicians in favor of "patient autonomy." An understanding of such dynamic facets will help better tailor culturally appropriate approaches to such complex situations.

Time travel: the lived experience of providing feeding assistance to a family member with dementia

A major concern facing family members of people with advanced dementia is deciding how to provide food and water. Nurses play a significant role in supporting mealtimes, yet little is known about the meaning of mealtime for family caregivers of people with dementia. The purpose of this phenomenological study was to explore the experience of providing feeding assistance to a family member with dementia from the perspective of community and nursing home family caregivers. Data were collected through in-depth interviews with 16 family caregivers of individuals with advanced dementia. Analysis revealed that the experience was likened to living in a time warp whereby family caregivers were propelled from pleasant memories of the past, to the stark reality of the present, to a foreboding and uncertain future. Findings can guide nurses to dialogue with family members and to ensure that the full spectrum of mealtime is preserved.

Healthcare proxies of nursing home residents with advanced dementia: decisions they confront and their satisfaction with decision-making

OBJECTIVES

To describe the medical decisions confronting healthcare proxies (HCPs) of nursing home (NH) residents with advanced dementia and to identify factors associated with greater decision-making satisfaction.

DESIGN

Prospective cohort study.

SETTING

Twenty-two Boston-area NHs.

PARTICIPANTS

Three hundred twenty-three NH residents with advanced dementia and their HCPs.

MEASUREMENTS

Decisions made by HCPs over 18 months were ascertained quarterly. After making a decision, HCPs completed the Decision Satisfaction Inventory (DSI) (range 0-100). Independent variables included HCP and resident sociodemographic characteristics, health status, and advance care planning. Multivariable linear regression identified factors associated with higher DSI scores (greater satisfaction).

RESULTS

Of 323 HCPs, 123 (38.1%) recalled making at least one medical decision; 232 decisions were made, concerning feeding problems (27.2%), infections (20.7%), pain (12.9%), dyspnea (8.2%), behavior problems (6.9%), hospitalizations (3.9%), cancer (3.0%), and other complications (17.2%). Mean DSI score +/- standard deviation was 78.4 +/- 19.5, indicating high overall satisfaction. NH provider involvement in shared decision-making was the area of least satisfaction. In adjusted analysis, greater decision-making satisfaction was associated with the resident living on a special care dementia unit (P=.002), greater resident comfort (P=.004), and the HCP not being the resident's child (P=.02).

CONCLUSION

HCPs of NH patients with advanced dementia can most commonly expect to encounter medical decisions relating to feeding problems, infections, and pain. Inadequate support from NH providers is the greatest source of HCP dissatisfaction with decision-making. Greater resident comfort and care in a special care dementia unit are potentially modifiable factors associated with greater decision-making satisfaction.

Feeding alternatives in patients with dementia: examining the evidence

Percutaneous endoscopic gastrostomy tubes are being placed with increasing frequency in the United States among elderly patients with dementia. Health care providers believe there may be long-term benefits for enteral feeding in this population, yet previous study of this topic has failed to yield any convincing evidence to support this hypothesis. In this study, we review the evidence regarding outcomes for artificial enteral feeding in older individuals with dementia. We found that there is a lack of evidence supporting artificial feeding in the specific outcomes of survival, pressure ulcers, nutrition, and aspiration pneumonia. A brief discussion regarding hand feeding is included. The data suggest that hand feeding may be a viable alternative to tube feeding in elderly patients with dementia, although a direct comparison trial of the 2 interventions is lacking.

The attitudes of Chinese family caregivers of older people with dementia towards life sustaining treatments

AIM

This paper is a report of a study to examine attitudes towards life-sustaining treatment in family caregivers of older Chinese people with dementia.

BACKGROUND

Deferring decisions about life-sustaining treatments to surrogate decision-makers is common among older people with dementia. However, surrogate decision-makers frequently lack knowledge about disadvantages and benefits of treatments and do not understand the principles of surrogate decision-making.

METHOD

A total of 51 Chinese family caregivers were interviewed during 2003 and 2004. The interview included an assessment of their knowledge about cardiopulmonary resuscitation and tube feeding, a questionnaire to assess their anticipated decisions for four treatments (cardiopulmonary resuscitation, artificial ventilation, tube feeding and antibiotic administration) if the older relative suffered critical illness or irreversible coma, and their comfort and certainty in making such decisions.

FINDINGS

Family caregivers displayed poor knowledge about life-sustaining treatments, with 30 (59%) and 13 (26%) unable to name any feature of cardiopulmonary resuscitation and tube feeding, respectively. Most relied on their own views in decision-making rather than on what they thought their relative would have wanted. Most family caregivers were reluctant to forgo treatments. Nursing home residence predicted family caregivers' willingness to forgo artificial ventilation for critical illness. Financial burden predicted inclination to forgo antibiotics for critical illness and irreversible coma, as well as tube feeding in irreversible coma.

CONCLUSION

More dialogue and education are needed about end of life issues in the early phase of dementia. Nurses should be aware of the cultural implications of surrogate decision-making for Chinese family caregivers.

Advance directives at end-of-life: nursing home resident preferences for artificial nutrition

OBJECTIVE

Nursing homes are increasingly the place where many Americans die. Thus, advance directives are critical to the preservation of the autonomous wishes at end-of-life. The purpose of this paper is to determine if preferences for artificial nutrition, as stated in the advance directives of nursing home residents, are honored in the last 2 months of life.

DESIGN

Secondary analysis.

SETTING

Six Maryland community nursing homes.

PARTICIPANTS

Fifty-seven consented residents (age 62 to 98) from the parent study who died during the study period.

MEASUREMENTS

Retrospective document review including advance directives and clinical care provided in the last 2 months of life.

RESULTS

Most of the nursing home residents in this sample refused feeding tubes, and these preferences were honored during the last 2 months of life (93%), despite some (17% to 26%) with documented weight loss. A small percentage (8.8%) of residents received feeding tubes at end-of-life and, of those, only 1 was consistent with advance directive preferences. Most advance directives in this study included feeding tube preferences.

CONCLUSION

In this nursing home sample, advance directives were significant documents guiding decisions on artificial nutrition, and feeding tubes were in fact uncommon at the end of life. The study suggests that advance care planning, quality palliative care training, and administrative support are necessary for the honoring of preferences. Future research is needed to examine more broadly tube-feeding practices and prevalence in nursing homes.

PEG-Ernährung bei fortgeschrittener Demenz

Lacking clear empirical evidence and ethical obligations, decision-making about tube-feeding in patients with advanced dementia often presents as a difficult problem in clinical routine. Based on the principles of beneficence, non-maleficence and autonomy, an ethical analysis of the empirical evidence shows that tube-feeding should be avoided in many patients with advanced dementia: Recent studies demonstrate (1) that there is no proof of any benefit, (2) that tube-feeding often results in further harm to the dementia patient and (3) that the patient's will is not sufficiently taken into consideration. A practical model for interdisciplinary decision-making can account for these various difficulties and might improve the empirically and ethically highly complex process of decision-making about tube feeding in patients with advanced dementia.

Satisfaction with end-of-life care for nursing home residents with advanced dementia

OBJECTIVES

To identify factors associated with satisfaction with care for healthcare proxies (HCPs) of nursing home (NH) residents with advanced dementia.

DESIGN

Cross-sectional study.

SETTING

Thirteen NHs in Boston.

PARTICIPANTS

One hundred forty-eight NH residents aged 65 and older with advanced dementia and their formally designated HCPs. MASUREMENTS: The dependent variable was HCPs' score on the Satisfaction With Care at the End of Life in Dementia (SWC-EOLD) scale (range 10-40; higher scores indicate greater satisfaction). Resident characteristics analyzed as independent variables were demographic information, functional and cognitive status, comfort, tube feeding, and advance care planning. HCP characteristics were demographic information, health status, mood, advance care planning, and communication. Multivariate stepwise linear regression was used to identify factors independently associated with higher SWC-EOLD score.

RESULTS

The mean ages+/-standard deviation of the 148 residents and HCPs were 85.0+/-8.1 and 59.1+/-11.7, respectively. The mean SWC-EOLD score was 31.0+/-4.2. After multivariate adjustment, variables independently associated with greater satisfaction were more than 15 minutes discussing advance directives with a care provider at the time of NH admission (parameter estimate=2.39, 95% confidence interval (CI)=1.16-3.61, P<.001), greater resident comfort (parameter estimate=0.10, 95% CI=0.02-0.17, P=.01), care in a specialized dementia unit (parameter estimate=1.48, 95% CI=0.25-2.71, P=.02), and no feeding tube (parameter estimate=2.87, 95% CI=0.46-5.25, P=.02).

CONCLUSION

Better communication, greater resident comfort, no tube feeding, and care in a specialized dementia unit are modifiable factors that may improve satisfaction with care in advanced dementia.

Enteral feeding in end-stage dementia: a comparison of religious, ethnic, and national differences in Canada and Israel

BACKGROUND

Although enteral feeding in end-stage dementia is thought by many clinicians to be "futile," it is still widely used. We examined rates of tube feeding (gastrostomy or nasogastric) in end-stage dementia in hospitals in both Canada and Israel, and hypothesized that Canadian non-Jewish affiliated hospitals would have the lowest (and Israeli institutions the highest), with Canadian Jewish hospitals exhibiting intermediate rates.

METHODS

We conducted a cross-sectional survey of six geriatric long-term hospitals: two in Israel and four in Canada (two Jewish affiliated, two not; two in Ontario, two in Quebec province). Patients with end-stage dementia were assessed and further analyzed for type of feeding.

RESULTS

In the six hospitals, 2287 long-term beds were surveyed, of which 1358 (59.4%) were used by demented patients of whom 376 (27.7%) were severely demented (Global Deterioration Scale-level 7). Of these, 24.5% (92) were fed by nasogastric tube or gastrostomy tube. Significant differences in tube-feeding prevalence were found between Canada (11%) and Israel (52.9%), with only 4.7% seen in non-Jewish Canadian institutions. Jewish affiliated hospitals in Canada exhibited an intermediate rate of 19.6%. However, for within-country dyads, wide differences were also found. When we examined patient religion, we found that Canadian non-Jewish patients had the lowest rates (3.2%), Israeli Jewish patients the highest (51.7%), and Canadian Jewish patients exhibited an intermediate rate (19.0%) of tube use.

CONCLUSIONS

Despite reservations concerning its utility, feeding tube use is reasonably widespread in patients who have reached the stage of severe dementia. Canadian institutions exhibited a lower prevalence of feeding tube use than did Israeli hospitals. Between-country and between-province differences in practice may be explained by some combination of administrative and/or financial incentives, religion, and culture; within-country and within-ethnic group differences may be caused, at least in part, by differing institutional cultures.

Advanced dementia research in the nursing home: the CASCADE study

Despite the growing number of persons with advanced dementia, and the need to improve their end-of-life care, few studies have addressed this important topic. The objectives of this report are to present the methodology established in the CASCADE (Choices, Attitudes, and Strategies for Care of Advanced Dementia at the End-of-Life) study, and to describe how challenges specific to this research were met. The CASCADE study is an ongoing, federally funded, 5-year prospective cohort study of nursing [nursing home (NH)] residents with advanced dementia and their health care proxies (HCPs) initiated in February 2003. Subjects were recruited from 15 facilities around Boston. The recruitment and data collection protocols are described. The demographic features, ownership, staffing, and quality of care of participant facilities are presented and compared to NHs nationwide. To date, 189 resident/HCP dyads have been enrolled. Baseline data are presented, demonstrating the success of the protocol in recruiting and repeatedly assessing NH residents with advanced dementia and their HCPs. Factors challenging and enabling implementation of the protocol are described. The CASCADE experience establishes the feasibility of conducting rigorous, multisite dementia NH research, and the described methodology serves as a detailed reference for subsequent CASCADE publications as results from the study emerge.

Expectations and outcomes of gastric feeding tubes

PURPOSE

To compare expected outcomes with actual outcomes from tube feeding in adult patients.

SUBJECTS AND METHODS

This prospective cohort study was conducted in two North Carolina hospitals. Surrogates were interviewed shortly after feeding tube insertion and at 3- and 6-month follow-up; chart abstraction and death certificate review also were carried out. Participants were surrogate decision-makers for consecutive adult patients who received new feeding tubes.

RESULTS

There were 288 patients with surrogate decision-makers enrolled. Mean age was 65 years; 30% had a primary diagnosis of stroke, 16% neurodegenerative disorder, 20% head and neck cancer, and 30% other diagnoses. At 3 months, 21% of patients had died, and 6-month mortality was 30%. At 3 months, 38% of survivors were residing in a nursing home, and 27% had the feeding tube removed. Patients were impaired in most activities of daily living (ADLs) with little change over time. Medical complications were common: 25% of patients had decubitus ulcers at 3 months, and 24% had at least one episode of pneumonia. Perceived global quality of life was poor at 4.6 (on a 0-10 scale) at baseline, and surrogates anticipated this would improve to 8.0 with tube feeding. Family surrogates' expectations for improvement from the feeding tube were very high at baseline and remained so at 3 and 6 months.

CONCLUSIONS

Families' high expectations of benefit from tube feeding are in contrast to clinical outcomes. Providers and families need better information about the outcomes of this common procedure.

Tube Feeding in Advanced Dementia: An Exploratory Survey of Physician Knowledge

The administration of artificial nutrition by means of a percutaneous endoscopic gastrostomy (PEG) tube in older persons in the advanced stages of dementia is commonplace, yet the treatment is associated with significant treatment burdens and unclear benefits in this population. In addition, there is wide and unexplained geographic variability in the use of PEG in advanced dementia, which may stem partly from physicians’ lack of understanding about its indications, risks, benefits, and effect on quality of life in advanced dementia. This study was a mail survey undertaken to assess physician knowledge regarding tube feeding in advanced dementia and explore whether certification in geriatrics or other physician characteristics are associated with physician knowledge. To assess knowledge about tube feeding, we asked participants to rate the importance of commonly cited, but non–evidence based, indications for tube feeding in advanced dementia, including recurrent aspiration pneumonia, abnormal swallowing evaluations, abnormal nutritional parameters, preventing an uncomfortable death, and others. Discrepancies between physician knowledge and current evidence regarding tube feeding in advanced dementia were found, indicating a need for improved education of primary care physicians in order to ultimately provide better end-of-life care for patients with advanced dementia.